Chest pain triage: Current trends in the emergency departments in the United States

Abstract

Chest pain is one of the most common complaints in the emergency department (ED). Over the past decade, there has been a significant shift in the approach to patients with chest pain in the ED. With the development of improved cardiac biomarkers, the validation of clinical scoring systems, and an increasing emphasis on shared patient medical decision making, increasing numbers of patients in the ED are being evaluated without requiring admission to the hospital.

Imaging for chest pain in the emergency room: Finding the right gate not the right gatekeeper

“…1 In this issue of the Journal of Nuclear Cardiology, Delaney et al review the variety of tools available to evaluate patients with acute chest pain in the Emergency Room. 3 Despite the vast amount of published data, no clinical consensus has been reached on the management of these patients. There are well established clinical guidelines for management of STEMI and NSTEMI/ acute coronary syndrome and multimodality appropriate use criterion for assessment of stable ischemic heart disease that have been embraced universally, [4][5][6] no such standards have the same level of acceptance for evaluation in the emergency room.…”

“…10,11 Similar findings of increased coronary angiography and revascularization have been reported by other authors. 3 Applying CTA to a lower risk population might further reduce downstream testing and cost. Reducing subsequent angiography and revascularization based on guidelines would also improve cost effectiveness.…”

“…3,[12][13][14][15] Patients enrolled in these studies are more heterogeneous, have baseline higher risks, and in fact often have known CAD. SPECT effectively predicted which patients would need to undergo coronary angiography.…”

Getting it right the first time: Stress-only MPI in the ER

“…2 Multiple clinical pathways have been developed incorporating biomarkers, functional testing, and noninvasive angiography, all of which have high success rates. 5 Although patients are no longer admitted, direct costs remain high ($2226-$3168) regardless of modality, driven to a great degree by length of stay in the hospital. 3 In order to reduce the cost, the focus should be on three critical factors-reduce the number of people requiring chest pain pathways, reduce utilization of advanced imaging, or decrease length of hospital stay.…”

Most patients are triaged using the emergency severity index

“…1 The study is remarkable because it reviews clinical scoring systems and highlights the important role of risk stratification among patients with chest pain in the emergency department (ED). Chest pain is a hallmark in triaging patients at risk for acute myocardial infarction (AMI), so it is critical to manage cardiac patients effectively.…”